My study was on Theory of Mind (ToM) and moral decision-making in Autism Spectrum Disorder (ASD). Therefore, I focused on specific social difficulties that ASD children may have, and I investigated ToM as a potential underlying mechanism. ToM pertains to perspective-taking, intention-detection and behavioural prediction abilities, and it has been associated with social difficulties in ASD. Moral decision-making falls under the broader construct of social decision-making and is likely to rely on ToM. Consequently, conceptualising the relationship between ToM and moral decision-making in ASD may provide insight into the social difficulties experienced by this clinical population.

My study aimed to compare moral decision-making in children with ASD and children without ASD, and to determine whether ToM plays a role in moral decision-making. Boys between 6 and 12 years old participated in my study, with a group of 38 boys with ASD, and a control group of 38 boys without ASD. The moral decision-making tasks looked at how children share (Dictator Game) and allocate resources in third-party social scenarios (Distributive Justicetask) based on generosity and judgement of fairness, respectively. The results from the Dictator Game showed that, although both groups responded to social information, the way in which they responded differed. The results from the Distributive Justice task were also significant. Across conditions representing social inequality based on wealth, merit and health, children without ASD allocated significantly more resources to the morally deserving recipient. In contrast, the children with ASD demonstrated a preference for allocating equally, regardless of the social information. The quotes also showed that the children with ASD showed a tendency to systemize rather than empathize in making moral decisions; this means that they were more likely to consider each social scenario presented to them as a fixed “system”. Using this approach, it is possible that they used rules to manipulate a phenomenon that they perceived to be lawful and predictable. The difficulty recognising that people are not rule-governed systems is a potential explanation for ASD children’s atypical social-decisions. Given the limited predictive power of systemizing in the social world, this type of approach in ASD could potentially result in social decision-making behaviour that society deems as inappropriate.

Lastly, my study also showed that ToM was a significant predictor of moral decision-making. Therefore, it is likely that the evident ToM difficulties in the ASD group may have disrupted the typical process of moral decision-making. More specifically, the ASD children may have had difficulty translating their empathic arousal into empathic concern and, in turn, may have been less motivated to behave “empathically” in making moral decisions. Therefore, I do not propose a lack of morality in ASD but rather a difficulty using social information in the application of moral principles due to ToM deficits.

Overall, the results of this study are significant as they point to atypical patterns of moral decision-making, and therefore social decision-making, in ASD as well as a potential underlying mechanism. This may aid people’s understanding of social impairment in South African children with ASD and lends support for the establishment of a predictive model for moral decision-making. Lastly, the acquisition of this knowledge may serve as foundational work to guide future research investigating the role of empathizing vs. systemizing in moral decision-making, within the context of ASD.

Thank you to all the families and schools for participating in my study!

UCT Autism ACSEPT recently published an article in the Journal of Child and Adolescent Mental Health where we
shared our insights on testing Theory of Mind in children with Autism Spectrum Disorder. This article highlighted
the need to consider other cognitive abilities during testing, and to ensure that all tests are appropriate. We thank all the families who have participated in our studies over the years for allowing us to gain this experience, and to now share this with other researchers and clinicians. We hope to keep learning more as our research continue.

Autism Spectrum Disorder (ASD) is characterised by poor social competence, and as Theory of Mind (ToM) is a building block for social-communicative skills and successful social integration, these skills are important to assess when preparing and monitoring educational and therapeutic plans. ToM is a complex skill requiring the ability to form mental concepts, to represent complex constructs verbally, to inhibit some mental states in favour of others, and to consider and compare multiple perspectives. It is critical to consider cognitive influences on the ability to develop and convey ToM skills to ensure that deficits in other cognitive domains do not falsely present as ToM deficits. This consideration is particularly vital in ASD populations with known difficulties not only in ToM, but also in intellectual functioning, language and executive functioning. This article reviews the influence of intellectual ability, language, working memory, and inhibition skills on the presentation of ToM, with particular focus on ToM in ASD. We discuss practical suggestions based on clinical experience in neuropsychological practice and research in South Africa for the successful assessment of ToM ability.

This article first appeared in the Fall edition of the International Society for Autism Research’s newsletter.

Autism research in the Global South (countries outside of North America and Europe, that is) faces many daunting obstacles, including the lack of prevalence data for autism and other developmental disorders. Another challenge is that, with the big burden of infectious diseases such as HIV and malaria – and now Zika – in these countries, there is a dire lack of funding for non-communicable and non-fatal diseases such as autism. These challenges mean that there is less government support for autism research and service delivery. Hopefully, obstacles such as these will foster creative research techniques: It challenges the research community to create low-cost and relatively culturally unbiased assessment tools – tools that are fair regardless of education, language, or race. Everyone stands to gain from increased research coming from developing countries: For example, populations in the Global South are typically linguistically, culturally, and genetically diverse, which can improve our understanding of the behavioral presentation and genetics of autism. Staggeringly, almost all genetic research has been done on middle-income individuals from European descent, though this by no means represents the global population.

Clearly, more international and interdisciplinary collaborations are needed. Research groups often do well by partnering with non-profit groups to promote research and raise autism awareness at the same time. Partnerships with the technology industry also hold promise for long-distance diagnosis and intervention. This may be particularly true in Africa, where people in rural areas sometimes have to travel for hours to access healthcare services, and where more people have a mobile phone than piped water or electricity at home. Collaborations are our best bet for moving towards research that includes low-income groups of diverse racial, linguistic and cultural backgrounds.

A challenge for international research is knowing when to follow standardized procedures originating from the Global North, and when to develop new techniques. Certainly, some problems will need to be approached differently in low-resource countries. For example, the ratio of professional healthcare providers to individuals seeking care is enormous in many countries in the Global South, and large-scale interventions delivered by specialized providers are unlikely to be sustainable. However, many cultures are very community-oriented – something researchers and healthcare providers can harness to provide intervention and safe spaces in areas where trained professionals are not available. Discussions between research groups facing similar problems can be helpful for fostering new ideas without reinventing the wheel.

It is promising that autism research coming from the Global South is increasing: It holds many challenges, but also great opportunity for improving the lives of countless people.

On the 12th and 13th of September I was privileged to attend the 16th Society for the Study of Behavioural Phenotypes International Research Symposium at the Stellenbosch Institute for Advanced Studies. This conference brought together international researchers and clinicians with experience in a variety of developmental disorders. The focus of the conference was exploring the biological bases of different disorders and the different clinical presentations within these disorders. Autism was one of the disorders under discussion.

I presented the preliminary results from my research towards my Masters in Clinical Neuropsychology. My research focused on the relationships between Autism Spectrum Disorder, Theory of Mind, and a candidate gene that is involved in the regulation of serotonin.

Theory of Mind is a form of social cognition that allows you to understand that other people have their own thoughts, emotions, and beliefs, and that these are separate to your own. We know that Theory of Mind development is often undermined in Autism, and as such we wanted to know whether it was it is a symptom on its own, or whether problems with Theory of Mind are because of one of the other main symptoms in Autism.

We were interested in serotonin because approximately one third of children with Autism present with increased serotonin in their bodies, but their symptoms are characteristic of someone who has too little serotonin. Serotonin is a natural chemical created in your body that is used in your brain for many different functions, one of which is social functioning. When someone has too little serotonin, they may struggle to cope in social situations, may have difficulties with anxiety, and have other mood difficulties. The specific gene we are investigating, called the Serotonin Transporter Promoter Length Polymorphism, or 5-HTTLPR, controls how effectively the brain uses serotonin. Therefore differences in this gene in people with Autism might explain the anxiety, difficulties with social functioning and difficulties with mood regulation associated with the condition. 5-HTTLPR has different forms or “polymorphisms” which affect this use of serotonin, so I wanted to see how different symptoms presented depending on whether children had the polymorphisms with typical serotonin transmission, or with reduced transmission.

I found that a certain polymorphism of the 5-HTTLPR gene may be involved in social communication within Autism, and we should therefore explore the serotonin system in greater detail to fully understand how this relationship works, and how to best use this information to assist individuals on the spectrum. Contrary to what was expected, I did not find relationships between Theory of Mind and measures of social competence, despite this being a relationship reported in typically developing individuals. Overall, my research concluded that we are getting closer to understanding how the 5-HTTLPR gene and serotonin are implicated in Autism Spectrum Disorders, but that there are still several other factors that need to be considered before we can draw clear behavioural profiles for each form of the gene.

I was honoured to meet with several international researchers and clinicians who are experts in the separate areas of my research. I was able to discuss my current research, as well as planned future research, and they provided invaluable advice. I learnt a great deal from these interactions and from the research presented. I believe that valuable progress is being made in genetic and biological research. Thank you to all the parents, children, and schools who make it possible for us to conduct this research. With each project we are another step closer to better understanding Autism.